Factors associated with high rates of caesarean section in Brazil between 1991 and 2006

Incidence and Determinants of Caesarean Section in Shiraz, Iran

The rate of Caesarean section (CS) without medical indication has increased markedly worldwide in the past decades. This study reports the incidence of CS and identifies the determinants of elective and emergency CS as separate pregnancy outcomes in a cohort of Iranian women. Mothers (n = 700) of healthy, full-term infants were recruited from five maternity hospitals in Shiraz. The association between maternal socio-demographic and biomedical factors with mode of delivery was explored using multivariable, multinomial logistic regression. Most mothers underwent either an elective (35.4%) or emergency (34.7%) CS. After adjustment, women were more likely to deliver by elective CS than vaginally if they were older (≥30 year) compared to younger mothers (<25 year) (Relative Risk Ratio (RRR) 2.22; 95% Confidence Interval (CI) 1.28, 3.84), and had given birth at a private hospital (RRR 3.64; 95% CI 1.79, 7.38). Compared to those educated to primary or lower secondary level, university educated women were more likely to have undergone an elective (RRR 2.65; 95% CI 1.54, 4.58) or an emergency CS (RRR 3.92; 95% CI 2.27, 6.78) than a vaginal delivery. Similarly, overweight or obese women were more likely than healthy weight women to have undergone an elective (RRR 1.91; 95% CI 1.27, 2.87) or an emergency CS (RRR 2.02; 95% CI 1.35, 3.02) than a vaginal delivery. Specialist education of obstetricians and midwives along with financial incentives paid to private hospitals to encourage natural delivery may help in the reduction of unnecessary CS in Iran. In addition, to increase their childbirth knowledge and self-efficacy, pregnant women need to have the opportunity to attend purposefully designed antenatal childbirth preparation classes where they receive evidence-based information on natural childbirth and alternative methods of pain control, as well as the risks and indications for CS.

Caesarean section in uninsured women in the USA: systematic review and meta-analysis

OBJECTIVE

The aim of this study is to assess the odds of caesarean section (CS) for uninsured women in the USA and understand the underlying mechanisms as well as consequences of lower use.

STUDY DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, the Cochrane Library and CINAHL from the first year of records to April 2018.

ELIGIBILITY CRITERIA

We included studies that reported data to allow the calculation of ORs of CS of uninsured as compared with insured women.

OUTCOMES

The prespecified primary outcome was the adjusted OR of deliveries by CS of uninsured women as compared with privately or publicly insured women. The prespecified secondary outcome was the crude OR of deliveries by CS of uninsured women as compared with insured women.

RESULTS

12 articles describing 16 separate studies involving more than 8.8 million women were included in this study. We found: 0.70 times lower odds of CS in uninsured as compared with privately insured women (95% CI 0.63 to 0.78), with no relevant heterogeneity between studies (τ2=0.01); and 0.92 times lower odds for CS in uninsured as compared with publicly insured women (95% CI 0.80 to 1.07), with no relevant heterogeneity between studies (τ2=0.02). We found 0.70 times lower odds in uninsured as compared with privately and publicly insured women (95% CI 0.69 to 0.72).

CONCLUSIONS

CSs are less likely to be performed in uninsured women as compared with insured women. While the higher rates for CS among privately insured women can be explained with financial incentives associated with private insurance, the lower odds among uninsured women draw attention at barriers to access for delivery care. In many regions, the rates for uninsured women are above, close or below the benchmarks for appropriate CS rates and could imply both, underuse and overuse.

Caesarean birth rates in public and privately funded hospitals: a cross-sectional study

OBJECTIVE

To examine maternal and obstetric factors influencing births by cesarean section according to health care funding.

METHODS

A cross-sectional study with data from Southeastern Brazil. Caesarean section births from February 2011 to July 2012 were included. Data were obtained from interviews with women whose care was publicly or privately funded, and from their obstetric and neonatal records. Univariate and multivariate analyses were conducted to generate crude and adjusted odds ratios (OR) with 95% confidence intervals (95%CI) for caesarean section births.

RESULTS

The overall caesarean section rate was 53% among 9,828 women for whom data were available, with the highest rates among women whose maternity care was privately funded. Reasons for performing a c-section were infrequently documented in women's maternity records. The variables that increased the likelihood of c-section regardless of health care funding were the following: paid employment, previous c-section, primiparity, antenatal and labor complications. Older maternal age, university education, and higher socioeconomic status were only associated with c-section in the public system.

CONCLUSIONS

Higher maternal socioeconomic status was associated with greater likelihood of a caesarean section birth in publicly funded settings, but not in the private sector, where funding source alone determined the mode of birth rather than maternal or obstetric characteristics. Maternal socioeconomic status and private healthcare funding continue to drive high rates of caesarean section births in Brazil, with women who have a higher socioeconomic status more likely to have a caesarean section birth in all birth settings.

Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis

OBJECTIVE

Financial incentives may encourage private for-profit providers to perform more caesarean section (CS) than non-profit hospitals. We therefore sought to determine the association of for-profit status of hospital and odds of CS.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the first year of records through February 2016.

ELIGIBILITY CRITERIA

To be eligible, studies had to report data to allow the calculation of ORs of CS comparing private for-profit hospitals with public or private non-profit hospitals in a specific geographic area.

OUTCOMES

The prespecified primary outcome was the adjusted OR of births delivered by CS in private for-profit hospitals as compared with public or private non-profit hospitals; the prespecified secondary outcome was the crude OR of CS in private for-profit hospitals as compared with public or private non-profit hospitals.

RESULTS

15 articles describing 17 separate studies in 4.1 million women were included. In a meta-analysis of 11 studies, the adjusted odds of delivery by CS was 1.41 higher in for-profit hospitals as compared with non-profit hospitals (95% CI 1.24 to 1.60) with no relevant heterogeneity between studies (τ²≤0.037). Findings were robust across subgroups of studies in stratified analyses. The meta-analysis of crude estimates from 16 studies revealed a somewhat more pronounced association (pooled OR 1.84, 95% CI 1.49 to 2.27) with moderate-to-high heterogeneity between studies (τ²≥0.179).

CONCLUSIONS

CS are more likely to be performed by for-profit hospitals as compared with non-profit hospitals. This holds true regardless of women's risk and contextual factors such as country, year or study design. Since financial incentives are likely to play an important role, we recommend examination of incentive structures of for-profit hospitals to identify strategies that encourage appropriate provision of CS.

Born in Brazil: shining a light for change

The Birth in Brazil study is the largest national hospital-based survey in Brazil regarding birth practices. Conducted in 2011–2012, it collected information from 266 public and private healthcare facilities and interviewed nearly 24,000 postpartum women. It is also the latest effort to map out how labor and delivery are managed in this county in the 21st century. The journal Reproductive Health has published a supplement including 10 articles presenting the results of a series of analyses using this valuable resource.

These articles describe a range of practices, determinants and risk factors that affect women and their babies in Brazil, a country of paradoxes. In the era of overmedicalization and high-tech medicine – arguably –, these articles highlight the unprecedented rates of cesarean sections in Brazil and differences between the public and the private sectors. It provides evidence for the need for adequate human resources, medications and emergency care equipment in many settings; and explains the use of non-evidence based interventions during labor and delivery. On the other hand, these studies also point to promising interventions that could be used to change this situation not only in Brazil but also in other countries facing similar challenges.

Colombian reference growth curves for height, weight, body mass index and head circumference

AIM

Published Growth studies from Latin America are limited to growth references from Argentina and Venezuela. The aim of this study was to construct reference growth curves for height, weight, body mass index (BMI) and head circumference of Colombian children in a format that is useful for following the growth of the individual child and as a tool for public health.

METHODS

Prospective measurements from 27 209 Colombian children from middle and upper socio-economic level families were processed using the generalised additive models for location, scale and shape (GAMLSS).

RESULTS

Descriptive statistics for length and height, weight, BMI and head circumference for age are given as raw and smoothed values. Final height was 172.3 cm for boys and 159.4 cm for girls. Weight at 18 years of age was 64.0 kg for boys and 54 kg for girls. Growth curves are presented in a ± 3 SD format using logarithmic axes.

CONCLUSION

The constructed reference growth curves are a start for following secular trends in Colombia and are also in the presented layout an optimal clinical tool for health care.